25 Aug 2022 Charles Evans · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 11 Lack of an emergency response procedure View source Lack of staff training in CPR View source Failure to establish and implement a service-provider action plan for improving quality and safety View source Lack of a proper procedure for staff to report concerns about residents View source Lack of reliable emergency communication facilities in the residents’ dining room View source Failure to ensure staff know who else is on duty View source Failure to conduct further risk assessments after a resident’s return from hospital View source Unavailability of a defibrillator on site View source Unavailability of a registered first aider on the premises View source Lack of staff presence in the communal dining room during mealtimes View source Failure to monitor progress towards the quality and safety action plan View source See 8 more concerns
Responses linked to these concerns
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AI-generated summary
Charles Evans · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Charles Evans, a resident at Hibiscus House, choked on food in the communal dining room on 29 May 2022, suffered cardiac arrest and severe hypoxic brain injury, and died in hospital the following day. The concerns included inadequate CPR and first-aid provision, absence of a defibrillator and emergency communication arrangements, insufficient staffing and emergency procedures in the dining room, and weaknesses in risk assessment and reporting processes.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hibiscus Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of an emergency response procedure
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hibiscus Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training in CPR
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR . The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hibiscus Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to establish and implement a service-provider action plan for improving quality and safety
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hibiscus Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a proper procedure for staff to report concerns about residents
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents ;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hibiscus Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of reliable emergency communication facilities in the residents’ dining room
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room . Staff were expected to use their mobile phone to call for help ;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hibiscus Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff know who else is on duty
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time ;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hibiscus Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct further risk assessments after a resident’s return from hospital
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hibiscus Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a defibrillator on site
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site ;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hibiscus Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a registered first aider on the premises
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises ;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hibiscus Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of staff presence in the communal dining room during mealtimes
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hibiscus Housing Association Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor progress towards the quality and safety action plan
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide formal first-aider training to four employees.
Verbatim wording from the response “On 17 October 2022 all employees of Hibiscus undertook First Aid Workplace Awareness training provided by High Speed Training. Additionally, four employees of Hibiscus will undertake First Aider Training via St John’s Ambulance which is scheduled for the end of October.” Source location Response from Hibiscus House
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Seek quotations for purchasing a permanently located on-site defibrillator.
Verbatim wording from the response “There is no compulsory requirement to purchase a defibrillator to comply with the Health and Safety (First-Aid) Regulations 1981. Hibiscus however have actively sought quotes for the purchase of a defibrillator which can be kept permanently on the premises. Once an appropriate defibrillator has been purchased, Hibiscus will ensure that all staff are aware of its location when contacting the emergency services and are fully trained in its use.” Source location Response from Hibiscus House
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Birdie electronic system for recording tenant observations, concerns, incidents and notes.
Verbatim wording from the response “Hibiscus has since implemented a new IT system called “Birdie”. This is accessible on computers and staff members’ phones, and it is used to log any observations and concerns about particular tenants. The Manager has access to all resident files on Birdie. The carers who have specific service users will only have access to their service user’s details in order to maintain data protection. Where a tenant requires a different carer (whether due to change of carer, holiday cover etc), the manager will allow the carer access to that resident’s file on Birdie.” Source location Response from Hibiscus House
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a written emergency procedure, embed it in risk assessments and the improvement plan, and train staff on it.
Verbatim wording from the response “Since this tragic incident Hibiscus have, with the assistance of their consultants, Delphi, and in conjunction with the CQC, implemented a formal procedure and provided training to its staff on the steps to take in an emergency situation. This procedure is now in written form reflected in risk assessments and forms part of Hibiscus’ new improvement plan. This is attached.” Source location Response from Hibiscus House
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Draw up an action plan addressing the three improvement areas identified by the CQC.
Verbatim wording from the response “The current Chief Officer ████████ has been in post since 3 March 2020 and upon joining Hibiscus drew up an Action Plan for the three areas of improvement which were identified by the CQC. Training had been put in place to address specific issues, however could not be undertaken for a significant length of time due to COVID restrictions. At this point work had already been undertaken to redesign care plans and upgrade systems which held vital information, but there was difficulty in implementing this. There was no monitoring of, or involvement by the CQC in this regard.” Source location Response from Hibiscus House
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide CPR training to all employees and refresh it annually.
Verbatim wording from the response “Hibiscus have engaged Delphi to assist in creating a planned programme of training. All employees of Hibiscus have now undertaken CPR training. CPR Awareness training commenced 29 July 2022 and was complete by 5 August 2022. This will be refreshed every year.” Source location Response from Hibiscus House
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a formal first-aid duty rota after the four employees complete first-aider training.
Verbatim wording from the response “There is no formal first aid duty rota in place, however with all staff being trained and the overlap of shifts which cover the week, there will always be at least one person who has first aid awareness on site. After the four employees have undertaken First Aider Training with St John’s Ambulance, a formal rota will be put in place.” Source location Response from Hibiscus House
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reassess tenants returning from hospital, including Care Manager risk assessment, ongoing observation and recording outcomes in tenant files and Birdie.
Verbatim wording from the response “Hibiscus has ensured that new procedures are in place for a reassessment should a tenant attend hospital and subsequently be discharged home. Faye Cadogan advised the Coroner at the inquest that where a tenant had attended hospital previously, the discharge letter was relied upon to inform the staff of any changes in that tenant’s needs.” Source location Response from Hibiscus House
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continuous staff supervision of the communal dining room is not considered necessary because the accommodation is not a nursing or residential care facility.
Verbatim wording from the response “It should be noted that there was no carer “on duty” at the time of Mr Evans’ incident. As Hibiscus is not a nursing facility there is no requirement to always have a person on duty at the premises. On the day, Mr Evans’ package of care services finished at approximately 7.00am and there was no further care planned for him that day. In the afternoon Mr Evans chose to have his lunch in the dining area which he was entitled to do. The dining area is a communal dining area and there is no requirement for it to be supervised.” Source location Response from Hibiscus House
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concern that no emergency alarm was available in the dining room is disputed because a functioning Care Link pull cord was installed there.
Verbatim wording from the response “6. There was no emergency bell/alarm or telephone in the residents dining room. Staff were expected to use their mobile phone to call for help.” Source location Response from Hibiscus House
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations